Is endoscopic totally extraperitoneal hernioplasty justified for the repair of groin hernia in female patients?

Background Groin hernia is an uncommon surgical pathology in females. The efficacy of the endoscopic approach for the repair of female groin hernia has yet to be examined. The current study was undertaken to compare the clinical outcomes of female patients who underwent open and endoscopic totally extraperitoneal inguinal or femoral hernioplasty (TEP). Methods From July 1998 to June 2004, 108 female patients who underwent elective repair of groin hernia were recruited. The patients were divided into TEP (n = 30) and open groups (n = 78) based on the type of operation. Clinical data and outcome parameters were compared between the two groups. Results The mean ages and hernia types were comparable between the two groups. All TEPs were successfully performed. The mean operative times were 52 min for unilateral TEP and 51 min for open repair. The difference was not statistically significant. Comparisons of the length of hospital stay, postoperative morbidity, pain score, and time taken to resume normal activities showed no significant differences between the two groups. A single patient in the TEP group experienced recurrence of hernia. Conclusions The findings show equivalent postoperative outcomes after TEP and open repair of groin hernia in female patients. Because the wound scar after open repair is well concealed beneath the pubic hair and no superior clinical benefits are observed after TEP, open repair appears to be the technique of choice for the management of primary groin hernia in females. The TEP approach should be reserved for female patients with recurrent or multiple groin hernia. The abstract was presented at the Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2005, 13–16 April 2005 at Fort Lauderdale, Florida     

A prospective evaluation of the PerFix® Plug technique for groin hernia repair

Summary The aim of the study was to prospectively evaluate complication rates, sick-leave, recurrence rate, and chronic post-operative pain after meshplug hernia repair. All 385 consecutive inguinal hernias (373 patients) operated at our department with the PerFix® Plug from September 1996 to December 1997 were included in the study. Follow-up included a questionnaire 3 and 12 months after the repair. Replies to the both of these questionnaires were obtained from 363 of 373 patients (98%). All patients who either reported a lump or sensory disturbance in the operated groin were offered a clinical examination. A third questionnaire focusing on chronic post-operative pain was completed by 77 of 90 patients reporting groin pain. The recurrence rate was 2% (9/385). After 25 months (17–36 months) 38 patients (10%) still experienced inguinal pain to some degree. In 7 male patients there was either pain or discomfort during sexual activities. In a patient with poorly controlled ascites the plug was removed. Day-case surgery was performed in 86% of patients with epidural or local anaesthesia, and 64% in general- or spinal anaesthesia. Employed/self-employed patients were off work for a median of 7 days (0–65). The median time to full recovery for all patients was 20 days. Conclusion: Mesh-plug hernia repair has a reasonably low complication rate together with quick recovery in a non-specialised surgical setting. Chronic inguinal pain is, however, still present to some degree in 10% of patients after two years.     

What is the reality in outpatient vs inpatient groin hernia repair? An analysis from the Herniamed Registry

Hernia - Groin hernia repair is performed increasingly more often as an outpatient procedure across the world. However, the rates are extremely different and vary between below 10% and above 90%....     

Perioperative outcome in groin hernia repair: what are the most important influencing factors?

Hernia - Using registry analyses, a large number of influencing factors on the perioperative outcome of groin hernia repair has been identified. The interactions between several influencing factors...     

Implementation of robot-assisted groin hernia repair diminishes the prospects of young surgeons’ training: a nationwide register-based cohort study

Hernia - Robot-assisted groin hernia repair is becoming more popular in recent years but may remove operations from surgical trainees. We aimed to investigate the educational level of the surgeons...     

The impact of comorbidities on postoperative outcomes of ventral hernia repair: the patients’ perspective

Hernia - Ventral hernia repair (VHR) outcomes can be adversely affected by modifiable patient co-morbidities, such as diabetes, obesity, and smoking. Although this concept is well accepted among...     

Validation of a questionnaire for the assessment of pain following ventral hernia repair—the VHPQ

Purpose

The aim of this study was to create and evaluate the validity and reliability of a novel ventral hernia pain questionnaire (VHPQ) to assess pain following surgery for ventral hernia.

Methods

The questionnaire was constructed using focus groups and patient interviews. Validity was tested on 51 patients who responded to the VHPQ and brief pain inventory (BPI) 1 and 4?weeks following surgery. Reliability and internal consistency was tested on 74 patients who had surgery 3?years earlier and received the VHPQ and BPI on two separate occasions. Pain not related to surgery was examined on one occasion using the VHPQ on 100 non-operated people.

Results

For pain intensity items, a significant decrease was seen from week 1 to week 4 postoperative (p?<?0.05). Spearman rank correlations were significant between the pain intensity items of the VHPQ and the BPI, tested 1?week postoperative (p?<?0.05). Kappa levels for test?Cretest of items for interference with daily activities were higher than 0.5 for all items except one. Intra-class correlation was significant for pain intensity items (p?<?0.05) in the test?Cretest group. Three years after surgery, the operated group stated more pain in the pain intensity items (p?<?0.05) and more interference with daily activities (p?<?0.05) than a non-operated group from the general population.

Conclusion

The validity and reliability of the VHPQ make it a useful tool in assessing postoperative pain and patient satisfaction.     

Laparoscopic ventral hernia repair in the elderly: does the type of hernia matter?

Purpose

Assess the impact of age and type of hernia on the outcomes of laparoscopic ventral hernia repair (LVHR).

Methods

Operating room database of all laparoscopic ventral hernias performed from April 2001 to July 2010 was analyzed retrospectively. Patients were divided into two groups: primary hernias (Group 1) and incisional hernias (Group 2). These groups were further stratified into patients <65?years of age (Groups 1A and 2A) and patients >65?years of age (Groups 1B and 2B). Patient demographics, hernia characteristics, perioperative outcomes, and disposition at discharge were compared. p-values <0.05 were considered significant.

Results

325 patients, with a mean age of 56.6?years (24–93?years) underwent LVHR. The mean length of stay (LOS) was longer (2.7?days vs 1.7?days, p value?=?0.02), and the rate of same day discharge was also significantly lower (12 vs. 25?%, p?=?0.02) for Group 2B when compared to Group 2A. Three patients in Group 2B, who had been living independently, were discharged to a skilled nursing facility, which proved significantly different when compared with Group 2A. There was no statistically significant difference in perioperative outcomes between younger and older subgroups with primary hernias.

Conclusions

LVHR in the elderly with incisional hernias have longer LOS and have a higher need for post-discharge nursing care unlike their counterparts with primary hernias. Identifying this cohort of patients early on helps the health-care providers to optimize the outcomes.     

Selecting patients during the “learning curve” of endoscopic Totally Extraperitoneal (TEP) hernia repair

Background

Totally Extraperitoneal (TEP) hernia surgery is associated with little postoperative pain and a fast recovery, but is a technically demanding operative procedure. Apart from the surgeon’s expertise, patient characteristics and hernia-related variations may also affect the operative time and outcome.

Methods

Patient-related factors predictive of perioperative complications, conversion to open anterior repair, and operative time were studied in a cohort of consecutive patients undergoing TEP hernia repair from 2005 to 2009.

Results

A total of 3,432 patients underwent TEP. The mean operative time was 26 min (SD ± 10.9), TEP was converted into an open anterior approach in 26 patients (0.8 %), and perioperative complications were observed in 55 (1.6 %) patients. Multivariable regression analysis showed that a history of abdominal surgery (OR 1.76, 95 per cent confidence interval 1.01–3.06; p = 0.05), and the presence of a scrotal (OR 5.31, 1.20–23.43; p = 0.03) or bilateral hernia (OR 2.25, 1.25–4.06; p = 0.01) were independent predictive factors of perioperative complications. Female gender (OR 5.30. 1.52–18.45; p = 0.01), a history of abdominal surgery (OR 3.96, 1.72– 9.12; p = 0.001), and the presence of a scrotal hernia (OR 34.84, 10.42–116.51, p < 0.001) were predictive factors for conversion. A BMI ≥ 25 (effect size (ES) 1.78, 95 % confidence interval 1.09–2.47; p < 0.001) and the presence of a scrotal (ES 5.81, 1.93–9.68; p = 0.003), indirect (ES 2.78, 2.05– 3.50, p < 0.001) or bilateral hernia (ES 10.19, 9.20–11.08; p < 0.001) were associated with a longer operative time.

Conclusion

Certain patient characteristics are, even in experienced TEP surgeons, associated with an increased risk of conversion and complications and a longer operative time. For the surgeon gaining experience with TEP, it seems advisable to select relatively young and slender male patients with a unilateral (non-scrotal) hernia and no previous abdominal surgery to enhance patient safety and ‘surgeon comfort’.     

Chronic groin pain following open inguinal hernia repair: has consenting practice improved?

IntroductionChronic groin pain following inguinal hernia surgery is a common and potentially debilitating complication, and yet patients are infrequently informed of this risk. This leaves surgeons open to negligence claims, especially given recent changes to case law, which for the first time highlighted the need for a more patient-centred approach to risk disclosure. We investigated how these changes have influenced our consenting practice with respect to the disclosure of this risk.MethodsWe compared how often surgeons discussed the risk of chronic groin pain with adults undergoing elective open unilateral inguinal hernia mesh repairs in 2019 and 2009. The first 50 patients in each of these two years were retrospectively compared. Discussions during the initial consultation and on the day of surgery were assessed by reviewing clinic letters, medical notes and consent forms.FindingsThe risk of chronic pain was discussed with significantly more patients in 2019 than in 2009 (96% v 54%, p<0.0001). Most of these discussions occurred on the day of surgery (92% v 54%, p<0.0001). Only a few patients had these discussions during their initial consultation (18% v 4%, p<0.025).ConclusionsDiscussing the risk of chronic groin pain has improved significantly over the past 10 years. However, these discussions occur mostly on the day of surgery, which gives patients very little time to weigh up the risk. This potentially invalidates the consent they give for surgery. Patients should be given an opportunity to discuss their operative risks in advance of their operation.     

Laparoscopic repair of incisional hernia in solid organ‐transplanted patients: the method of choice?

Due to immunosuppressive (IS) therapy, incisional hernias are overrepresented in the organ‐transplanted (Tx) population with larger defects, a high rate of recurrence, and a tendency toward more seromas and infectious problems. Thirty‐one Tx/IS patients with a control group of 70 non‐IS patients with incisional hernia (6/7 recurrences) were included in a prospective interventional study. Both cohorts were treated with laparoscopic ventral hernia repair (LVHR). Follow‐up time and rate was 37 months and 95%. One hundred LVHR's were completed as there was one conversion in the Tx/IS group. No late infections or mesh removals occurred. Recurrence rates were 9.7% vs. 4.2% (P = 0.37) and the overall complication rates were 19% vs. 27% (P = 0.80). The Tx/IS group had a higher mesh‐protrusion rate (29% vs. 13%, P = 0.09), but also larger hernias. Polycystic kidney disease was overrepresented in the Tx cohort (44% of kidney‐Tx). Incisional hernias in Tx/IS patients may be treated by LVHR with the same low complication rate and recurrence rate as non‐IS patients. By LVHR, the highly problematic seroma/infection problems encountered in Tx/IS patients treated by conventional open technique seem almost eliminated. The minimally invasive procedure seems particularly rational in the Tx/Is population and should be the method of choice. (ClinicalTrials.gov number: NCT00455299, date: 5 May 2006).     

Risk factors for surgical site infection after groin hernia repair: does the mesh or technique matter?

Hernia - Surgical site infections (SSIs) following groin hernia repair (GHR) are getting rarer in high income countries despite a wider use of meshes. Among the risk factors for SSIs, those related...     

Laparoscopic inguinal hernia repair: gold standard in bilateral hernia repair? Results of more than 2800 patients in comparison to literature

Background  

Advantages and disadvantages of open and endoscopic hernia surgery are still being discussed. Until now there has been no study that evaluated the advantages and disadvantages of bilateral hernia repair in a large number of patients.     

Female ‘groin’ hernia: totally extraperitoneal (TEP) endoscopic repair seems the most appropriate treatment modality

Background

About 30% of all female ‘groin’ hernias are femoral hernias, although often only diagnosed during surgery. A Lichtenstein repair though, as preferred treatment modality according to guidelines, would not diagnose and treat femoral hernias. Totally extraperitoneal (TEP) hernia repair, however, offers the advantage of being an appropriate modality for the diagnosis and subsequent treatment of both inguinal and femoral hernias. TEP therefore seems an appealing surgical technique for women with groin hernias.

Methods

This study included all female patients ≥18?years operated for a groin hernia between 2005 and 2009.

Results

A total of 183 groin hernias were repaired in 164 women. TEP was performed in 85% of women; the other 24 women underwent an open anterior (mesh) repair. Peroperatively, femoral hernias were observed in 23% of patients with primary hernias and 35% of patients with recurrent hernias. There were 30 cases (18.3%) of an incorrect preoperative diagnosis. Peroperatively, femoral hernias were observed in 17.3% of women who were diagnosed with an inguinal hernia before surgery. In addition, inguinal hernias were found in 24.0% of women who were diagnosed with a femoral hernia preoperatively. After a follow-up of 25?months, moderate to severe (VAS 4-10) postoperative pain was reported by 8 of 125 patients (6.4%) after TEP and 5 of 23 patients (21.7%) after open hernia repair (P?=?0.03). Five patients had a recurrent hernia, two following TEP (1.4%) and three following open anterior repair (12.5%, P?=?0.02). Two of these three patients presented with a femoral recurrence after a previous repair of an inguinal hernia.

Conclusion

Femoral hernias are common in women with groin hernias, but not always detected preoperatively; this argues for the use of a preperitoneal approach. TEP hernia repair combines the advantage of a peroperative diagnosis and subsequent appropriate treatment with the known good clinical outcomes.     

Pitfalls in retromuscular mesh repair for incisional hernia: The importance of the “fatty triangle”

Open retromuscular mesh repair has become a standard procedure in incisional hernia repair. This technique led to a significant decrease of recurrences. Recurrences after this technique typically occur at the upper mesh border and are a result of the technical complexity of reaching the postulated underlay of 5 cm in the region of the linea alba. We performed an anatomical study in human corpses to investigate the abdominal wall with its different structures, with emphasis on the overlap of the mesh under the linea alba. The overlap can be achieved by incision of the posterior lamina of the rectus sheath, on both sides close to the linea alba. The incision opens the preperitoneal space and appears in the shape of a fatty triangle. The anterior lamina of the rectus sheath above the hernia defect remains intact and facilitates a sufficient thrust bearing for a retromuscular mesh implantation. Knowledge of the anatomy and preparation of the fatty triangle enables a mesh positioning according to the principles of retromuscular mesh repair.     

Robotic inguinal hernia repair: Is it a new era in the management of inguinal hernia?

ObjectiveWe compared outcomes of elective inguinal hernia repair performed at one institution by three approaches: robotic-assistance, laparoscopic, and open.MethodsCharacteristics of the patients, the hernia and the procedures performed during 2014–2016 were accessed from patient electronic medical files of 137 elective inguinal hernia repairs. 24 surgeries were robotic-assisted, 16 laparoscopic and 97 open repairs.ResultsDistributions of age, sex and BMI did not differ between the groups. Bilateral repair was more common in the robotic (70.8%) than the laparoscopic (50.0%) and open groups (12.4%) (p < 0.001). Direct hernias were more common in the open (45.4%) than the robotic (20.8%) and laparoscopic (12.5%) groups (p < 0.001). Only 3 hernias were inguinoscrotal, all in the robotic group. The median operation times were 44.0, 79.0 and 92.5 min for the open, laparoscopic and robotic methods, respectively (p < 0.001). Among the unilateral repairs, the median operative times were the same for the robotic and laparoscopic procedures, 73 min, and less for the open procedures, 40 min. The proportion of patients hospitalized for 2–3 days was higher for open repair (13.4% vs. 6.2% and 0% for laparoscopic and robotic), but this difference was not statistically significant. The median maximal postoperative pain according to a 0-10-point visual analogue score was 5.0, 2.0 and 0 for open, laparoscopic and robotic procedures, respectively (p < 0.001).ConclusionsThis report demonstrated the safety and feasibility of robotic-assisted inguinal hernia repair.     

DynaMesh® in the repair of laparoscopic ventral hernia: a prospective trial

Purpose

To investigate mesh-related complications in patients undergoing laparoscopic ventral hernia repair using DynaMesh^®.

Methods

In the period 1 January 2005 through 31 December 2010, 181 consecutive patients undergoing laparoscopic ventral hernia repair in our day surgery unit using DynaMesh^® were entered prospectively in the National Danish Hernia Database. Data concerning abdominal reoperations after hernia repair were later collected on all 181 patients from the National Danish Health Registry. Postoperative telephone interviews were conducted estimating postoperative pain and patient satisfaction.

Results

Six % (11 patients) were reoperated because of mesh-related complications. Three had small bowel obstruction and one had a colonic fistula with mesh infection, all causing bowel resection and mesh removal. Mesh-related cutaneous fistula was seen in one patient. Six patients had a symptomatic recurrence requiring reoperation. Abdominal wall hematomas were seen in two cases, while two other patients had symptomatic large seromas, of which one was drained surgically. After a median follow-up of 34 months (range 12–63) in 140 patients, 66 % were pain free (0 on the Numeric Rating Scale (NRS)). Of 26 patients with moderate to severe pain (NRS > 3) at follow-up, only 4 regretted the operation. Sixteen patients thought they had a recurrence, of these only 3 regretted the operation.

Conclusion

The use of DynaMesh^® in laparoscopic ventral hernia repair was associated with a 6 % risk of mesh-related reoperation in a high volume setting. Despite chronic pain in 19 %, after 34 months follow-up patient satisfaction was high.